Managing serious cases of ocular trauma

Three ophthalmologists with extensive experience discuss their approach to managing serious ocular trauma in this review article. The key is remembering a few general principles, which they outline. First, make sure there are no associated injuries, check whether the globe is open or closed. Closed globe injuries require different management from open globe injuries. In the event of a traumatic accident, the presence of occult injury should be determined.

If a complete fundus examination by slit lamp is limited by corneal injury or intraocular blood, get a CT scan to check for the possibility of an intraocular foreign body. Clinicians must rule out penetration of the globe. Usually this is self evident on exam, but at times this injury can be subtle and difficult to diagnose without some digging. Significant findings for globe penetration are a lower intraocular pressure (IOP), pupillary asymmetry or distortion, a shallowing of the A/C, or even unusually significant hemorrhagic chemosis.

 Treatment algorithms are detailed for closing the globe in the article as well as repairing posterior pole damage, which may be done in two stages with immediate globe closure followed later vitreo-retinal repair.

It's also important to be on the lookout for  orbital trauma with fracture as well as orbital compartment syndrome. For the latter, a canthotomy is sometimes helpful to relieve increased IOP. Compartment syndrome can rapidly lead to vision loss if not managed properly.

 Lastly, remember to check new patients' histories for past trauma. Late complications from earlier trauma are always a possibility.